Adult New Patient Health History Form "*" indicates required fields Patient InformationFamily Care Clinic location you are registering for: Family Care Clinic - Hospital, Professional Office Building 1 Family Care Clinic - Main Avenue SW First Name* Last Name* Email* Date of Birth MM slash DD slash YYYY Today's Date MM slash DD slash YYYY Previous Primary Care Physician Reason for Today's Visit Current Medical HistoryHealth MaintenancePlease check if you've had any of the following: Colonoscopy Bone Density PAP Smear Mammogram Prostate Exam Eye Exam If you checked any of the above, please list the year performed below:Please check if you've had any of the following vaccines: Flu Tetanus Pneumonia Shingles If you checked any of the above, please list the year performed below:Prior Surgical HistoryPlease click the plus sign to the far right to add additional rows as needed.Type of SurgeryYear PerformedSurgeon Name Add RemoveFamily HistoryPlease list any family history including the illness and reason for death.Social HistoryDo you drink? Yes No Do you use tobacco products? Yes No Any illicit drug use? Yes No Do you drink caffeine? Yes No What is your occupation? Do you use any of the following? CPAP Glucose strips Nebulizer Oxygen Walker Wheelchair Hospital bed Do you have routine transportation? Yes No Current Pharmacy Allergies List ALL medications including herbal remedies, vitamins, over-the-counter, street drugs and prescriptions. (Click the plus sign to the far right to add additional rows)MedicationDosage Add RemoveOB/GYN HistoryLast Menstrual Period Do you have irregular or heavy periods? Yes No Have you ever been pregnant? Yes No If so, please list number of pregnancies and number of children.Do you have or have you ever had any of the following symptoms? (Check all that apply) Acid Reflux Anxiety/Depression Arthritis Asthma/COPD Bleeding Disorders Blood clots Blood in stool Blood in urine Breast abnormalities Changes in moles Constipation Diabetes Diarrhea Dizziness Headaches Hearing problems Heart problems Hepatitis High blood pressure HIV Joint Problems Lesions Liver problems Mood swings Nausea/vomiting Nipple discharge Problems urinating Rashes Seizures Sinus problems Sleep Apnea STD's Testicular pain Testicular swelling Thyroid problems Urinary tract infections Unplanned weight loss Vision problems If you answered yes to any of the above symptoms, please explain below:Please list any other conditions/illnesses not indicated above:To the best of my knowledge, this information is complete and correct. I understand that it is my responsibility to inform my healthcare provider if there are any changes in my health.CAPTCHA Δ